EP.TU.373What We Do In The Shadows: Night Surgical Registrars and Abdominal Pain

Aim Surgical cover at night differ according to hospitals and are often performed by junior registrars. This can be challenging as a certain amount of independence is required in decision making. Abdominal pain remains one of the most common surgical presentations in the Emergency Department. This study analyses the type of abdominal pain presentations that were reviewed overnight in a regional Australian hospital. Method All patient presentations requiring surgical review from 9.00pm to 7.00am over a period of 4 months are prospectively collected and analysed. Patient details collected comprised of gender, date of review, blood tests, imaging results, histopathology, and intra-operative findings. Results Of the 114 patients who presented with abdominal pain, the majority of them were undifferentiated abdominal pain (n = 20, 17.1%). This is then followed by appendicitis (n = 17, 14.5%), diverticulitis (n = 13, 11.1%), pancreatitis (n = 8, 6.8%) and cholecystitis (n = 6, 5.1%). Among the others, a total of 8 presentations required urgent surgical review which resulted in three emergency surgeries being performed overnight, a laparotomy for closed loop small bowel obstruction, a Hartmann's procedure and a laparoscopic appendicectomy on a septic patient. Conclusion Common presentations for abdominal pain overnight include undifferentiated abdominal pain, appendicitis, diverticulitis, cholecystitis and pancreatitis. Hence education for night surgical registrars should be focused on management of these common conditions and also on surgical emergencies such as closed loop bowel obstructions, septic patients and perforated viscus to ensure optimal patient outcome without the need for close supervision.

A Rare Case of Botulism in an Adult Patient

Presentation of botulism in adults is extremely rare and symptoms can be easily confused for symptoms of acute stroke, Guillain-Barre, or myasthenia gravis. The purpose of this clinical case report is to ensure adult botulism will be included in the differential diagnoses for a patient with this presentation so swift and accurate care can be provided to ensure optimal patient outcome. A 41-year-old-female presented with complaints of sudden onset of difficulty speaking. The patient reports a history of intravenous polysubstance abuse and symptoms progressed to bilateral facial weakness, ptosis, and external ophthalmoplegia. With no notable findings from a non-contrast computed tomography and magnetic resonance imaging and given the symptoms, a diagnosis of wound botulism from intravenous drug use was made. Botulism antitoxin was given and the patient was admitted into the intensive care unit for supportive follow-up care. A colony of Clostridium species was discovered in this patient’s arm and the patient showed significant improvement after a few days of care.

Treating the treatment: chemotherapy-induced multi-organ toxicity

A 40-year-old man presented to a local hospital with a 2-day history of dyspnoea having been started on adjuvant chemotherapy consisting of oxaliplatin and capecitabine for mucinous adenocarcinoma of the colon. During his admission, he develops chest pain, worsening shortness of breath, and intermittent dysarthria and disorientation. Investigations reveal severely impaired left ventricular function on echocardiogram, bilateral acute pulmonary embolisms on CT pulmonary angiogragraphy, and diffused subcortical and callosal white matter signal change and restricted diffusion consistent with a toxic leukoencephalopathy on MRI of brain. This case highlights the pivotal role of the multidisciplinary cardio-oncology approach which enabled these challenging diagnoses to be made and ensured optimal patient outcome.

Intramedullary Spinal Cord Tumors

Intramedullary spinal cord tumors represent a heterogeneous group of neoplasms that may cause progressive spinal cord dysfunction. With few exceptions, however, most are slow-growing, biologically indolent neoplasms for which surgery is the treatment of choice. Long-term tumor control with preservation of neurological function is achievable in most patients. Challenges to the evaluation and management of these lesions include accurate differentiation of these tumors from inflammatory conditions such as transverse myelitis, sarcoidosis, and demyelinating conditions; the management of patients with asymptomatic tumors; and the timing and techniques of surgery to achieve the optimal patient outcome.

Clozapine-Induced Agranulocytosis Revealing a Hemophagocytic Lymphohistiocytosis: A Case Report

Context: The aim of this report is to illustrate a case of hemophagocytic lymphohistiocytosis (HLH) that was revealed in the context of treatment-resistant first-episode psychosis. The incidence of this life-threatening condition is increasing in adults. Prompt diagnosis and treatment are important for an optimal patient outcome. Case Report: The patient was a 20-year old female who had been admitted to the inpatient unit of a Psychiatric Hospital for disorganized behavior with psychotic features. Clozapine had been introduced as the clinical picture did not evolve despite several trials of antipsychotics. As severe agranulocytosis developed, the patient was transferred to a general hospital. A diagnosis of HLH was suggested. Patient responded well to treatment, and remission of psychotic symptoms was observed. Conclusion: This case demonstrates the occurrence of HLH in a complicated clinical scenario involving psychotic experiences and the use of clozapine. Further studies are necessary to understand the potential environmental and pathological factors related to HLH

Case Factors Affecting Hearing Aid Recommendations by Hearing Care Professionals

Background: Professional recommendations to patients concerning hearing instrument (HI) technology levels are not currently evidence-based. Pre-fitting parameters have not been proven to be the primary indicators for optimal patient outcome with different HI technology levels. This results in subjective decision-making as regards the technology level recommendation made by professionals. Purpose: The objective of this study is to gain insight into the decision-making criteria utilized by professionals when recommending HI technology levels to hearing-impaired patients. Research Design: A set of patient variables (and their respective levels) was identified by professionals as determinant for their recommendation of HIs. An experimental design was developed and 21 representative patient cases were generated. The design was based on a contrastive vignette technique according to which different types of vignettes (patient cases) were randomly presented to respondents in an online survey. Based on these patient cases, professionals were asked in the survey to make a treatment recommendation. Study Sample: The online survey was sent to approximately 3,500 professionals from the US, Germany, France, and Italy. The professionals were randomly selected from the databases of Oticon sales companies. The manufacturer sponsoring the survey remained anonymous and was only revealed after completing the survey, if requested by the respondent. The response rate was 20.5%. Data Collection and Analysis: Data comprised of respondent descriptions and patient case recommendations that were collected from the online survey. A binary logit modeling approach was used to identify the variables that discriminate between the respondents' recommendations of HI technology levels. Results: The results show that HI technology levels are recommended by professionals based on their perception of the patient's activity level in life, the level of HI usage for experienced users, their age, and their speech discrimination score. Surprisingly, the patient's lifestyle as perceived by the hearing care professional, followed by speech discrimination, were the strongest factors in explaining treatment recommendation. An active patient with poor speech discrimination had a 17% chance of being recommended the highest technology level HI. For a very active patient with good speech discrimination, the probability increases to 68%. Conclusions: The discrepancies in HI technology level recommendations are not justified by academic research or evidence of optimal patient outcome with a different HI technology level. The paradigm of lifestyle as the significant variable identified in this study is apparently deeply anchored in the mindset of the professional despite the lack of supporting evidence. These results call for a shift in the professional's technology level recommendation practice, from nonevidence-based to a proven practice that can maximize patient outcome.

Symptomatic despite Multiple Drug Therapy: Where do you Turn Next?

Clinicians may be reluctant to implement evidence-based guideline recommendations because they believe that patients with chronic heart failure (CHF) who are enrolled into clinical trials are not truly representative of those seen in routine practice. Moreover, there may also be perceived safety issues associated with polypharmacy in patients with CHF. Clinicians should strive to implement guideline recommendations for the management of CHF to ensure optimal patient outcome in routine clinical practice. This case report demonstrates that symptom control may require a large number of pharmacological treatments, to be administered in accordance with guidelines.